Surgery is an essential component of healthcare worldwide. However
in industrialised countries, major complications occur in 3-16% of all
inpatient surgical procedures, with permanent disability or death rates
affecting approximately 0.4 - 0.8% of patients (Haynes et al 2009).

Between April 2007 and March 2008, there were 135,247 incidents
reported to the National Patient Safety Agency relating to surgical
specialties in England and Wales. Dr Atul Gawande, lead for the World
Health Organisation's (WHO) Safe Surgery Saves Lives campaign, has
said that at least half of all adverse events that occur in surgery
worldwide are avoidable (Gawande 1992).

The NPSA believes that by encouraging healthcare staff to be more
open and report incidents to its Reporting and Learning System (RLS),
learning can be achieved and subsequently avoidable harm to patients
will be reduced. The RLS is therefore an invaluable resource for
identifying the risks and system weaknesses which may not always be
apparent at local levels.

The NPSA has a dedicated Anaesthesia and Surgery team which aims to
improve patient safety in anaesthesia and surgery by working in
collaboration with the frontline staff, healthcare organisations,
relevant colleges and associations as well as other stakeholders. The
learning identified from incidents reported to the RLS is used to
prioritise the programme of work for the team.

One of the key mechanisms by which the Team fulfills its charter is
through the Clinical Board for Surgical Safety which the Chief Medical
Officer recommended to be established in his Annual Report 2007
(Donaldson 2008). The Board is a multi professional group including
surgeons, anaesthetists, nursing bodies and other relevant professional
organisations and meets on a quarterly basis. The purpose of this unique
group is to facilitate a more inclusive, collaborative and coordinated
approach to the strategic direction for patient safety in surgery.
Operationally, the Board provides advice to the NPSA on priorities
related to emergent surgical safety risks and the most appropriate
methods of communication and dissemination of these risks, as well as
monitoring the implementation status of previously released guidance.

The following section outlines the work in relation to surgery that
the NPSA's A&S team is currently involved in.

Surgical Safety Checklist

Earlier this year the NPSA issued a Patient Safety Alert on using
the WHO's Surgical Safety Checklist for every surgical procedure
(NPSA 2009). Implementation has been led by the Patient Safety First
Campaign in England and the 1000 Lives Campaign in Wales.

NHS organisations have until February 2010 to fully implement the
Alert's recommendations.

In addition to this, the NPSA is working with the Royal Colleges of
Ophthalmologists and Radiologists to refine the checklist so that it can
support the needs of their specialist members. These are currently
planned for release in early 2010.

Rapid Response Reports

Just over 1% (1,502) of the 135,247 surgical incidents reported to
the RLS resulted in serious harm or death. Each of these incidents has
been reviewed by clinical experts in the NPSA so that lessons can be
learnt across the NHS.

If evidence of preventable and substantive risk is found during the
incident reviews, the NPSA issues a Rapid Response Report which contains
clear and specific actions for healthcare organisations to reduce harm.

The most recent reports relating to surgery that have been issued
are:

Avoiding wrong side burr holes / craniotomy (November 2008)

This was based on evidence from 15 incidents of patients receiving
surgery on the wrong side of their heads (through wrong side burr holes
or craniotomies). Specific actions include marking the intended surgical
site, having a time out prior to final positioning, inserting of head
pins, auditing local practice and reporting further incidents.

Mitigating surgical risk in patients undergoing hip arthroplasty
for fractures of the proximal femur (March 2009) This was based on
evidence from 26 patient deaths and six cases of severe harm where bone
cement was used during hip surgery. Most occurred during emergency
hemiarthroplasties. The use of cement is indicated in certain clinical
situations, however for all hip arthroplasties for proximal femoral
fractures, clinicians should undertake a risk-benefit assessment to
mitigate harm.

For more information on these, visit the NPSA website:
http://www.npsa.nhs.uk/nrls/alerts-anddirectives/ rapidrr/

This following section outlines work under consideration and or in
progress and will be subject to further discussion at the Clinical Board
for Surgical Safety.

There are two Rapid Response Reports currently being developed:

Minimising the risks of using tourniquets for finger and toe
surgery

This is based on evidence from 14 incidents between 2003 - 2009
where non inflatable tourniquets for finger and toe surgery have been
left in situ and resulted in significant harm to the patient including
further surgical treatment and amputation of the affected digit. Simple
measures that have been suggested are the inclusion of the tourniquets
to swab and instrument counts, using brightly coloured, easily
identifiable commercial tourniquets and including the use of tourniquets
to the Surgical Safety Checklist.

Reducing the risk of perforation during laparoscopic surgery

This is based on 91 reported incidents relating to perforations
during laparoscopic surgery; 14 of which resulted in the patient death
either during the procedure or postoperatively. Potential risk reduction
strategies include review of the training and supervision of medical
staff, post-operative care (including recognition of the signs of
deterioration) and national audit.

Management of Tracheostomies

The NPSA issued guidance relating to 'Protecting Patients who
are Neck Breathers' in March 2005 (NPSA 2005). This focused on the
management of patients with tracheostomies and laryngectomies when
requiring emergency care.

The NPSA continues to receive incidents related to tracheostomy
management, so in collaboration with clinical experts the A&S team
is now considering further guidance relating to safe tracheostomy care.

The NPSA's Anaesthesia and Surgery team will be at this
year's AfPP Congress in October--stand number A38. They will be
available to provide further information regarding any of the above or
to discuss any other patient safety issues in anaesthesia and surgery.

References

Donaldson, L 2008 On the State of Public Health: 2007 Annual Report
of the Chief Medical Officer London, DH